Instructions: This form is to be completed after a critical event which causes, or is likely to cause, changes in the plan of care. This is an important step in the process of preventing new critical incidents, improving the care, treatment, and services for participant, and changing systems and processes to improve outcomes. Report is completed online and UIC pod leader and Department head should be notified of incident so a review conference can occur within 5 days. If unable to complete online, Completed original form should be should be placed in the participant s file. After internal review, a copy should be faxed to UIC at 217-586-6059. 1. Date of Report (MM/DD/YYYY): 2. RIN: 3. Participant Name: 4. Current address: 5. Program: DD DMH IDOA DRS Reporter Information (if other than participant) 6. Name: 7. Title: 8. Phone: ( ) 9. Email Address: 10. Agency Name: 11. Address 12. City 13. Zip Transition Coordinator Information 14. Name: 15. Phone: ( ) 16. Agency Name: 17. Email: 18. Address: Incident Information 19. Date of Incident (MM/DD/YYYY): 20. Time of Incident: a.m. or p.m. 21. Location of Incident: 22. Date incident discovered by TC (MM/DD/YYYY): 23. Time incident discovered: a.m. or p.m. 24. Did reporter directly observe incident? Yes No Self-report N/A 25. Were other individuals involved in the incident? Yes No Information about Other Person(s) Involved in Incident, if any a. First and Last Name b. Address, City, Zip c. Phone d. Gender e. Age 26. ( ) 27. ( ) M F M F f. Relationship to participant Self Family Caregiver Paid care worker Self Family Caregiver Paid care worker
28. ( ) Incident Type 29. Death (Preventable, Questionable, or Unexpected) 30. Alleged Fraud/Misuse of Funds Accidental Suicide Unusual Circumstances Unexpected or Sudden Death By participant By provider By both M F 31. Suicide Attempt 32. Nursing Facility Placement First Known Attempt Repeated Attempt If yes, Reason: 33. Unexpected Hospital Visit 34. Property Damage ER visit illness ER visit injury Medical Hospitalization Psychiatric Hospitalization Damage of provider property Damage of participant property 35. Behavioral Incident Involving Participant 36. Criminal Activity Page 2 of 6 Self Family Caregiver Paid care worker If yes, explain: Alleged victim Alleged perpetrator 37. Assault 38. Missing Person Sexual Assault alleged victim Sexual assault alleged perpetrator Law enforcement contacted Law enforcement not contacted Physical assault alleged victim Physical assault alleged perpetrator 39. Fire 40. Vehicle Accident Intentional started by individual Intentional not started by individual Participant vehicle Public transportation Pedestrian Accidental started by individual Accidental not started by individual vehicle 41. Suspected Mistreatment (abuse, neglect, exploitation) 42. Physical Altercation Alleged victim of physical abuse Alleged victim of verbal abuse Individual to individual alleged victim Individual to individual alleged perpetrator Alleged victim of neglect Alleged victim of exploitation 43. Other serious Injury to Participant Fall Bleeding Medication related Cut or puncture wound Bruising Sprain/strain Burn other
Please describe the critical incident in more detail: MFP Critical Incident Report Form M Page 3 of 6
Page 4 of 6 44. If serious injury occurred - check all that apply: Inflicted by self Inflicted by caregiver Inflicted by peer Inflicted by other Environmental Fall Equipment Transfer/Handling PICA/eating nonfood Insect/animal bite Motor vehicle Seizure items Unknown If serious injury occurred, please describe in more detail: 45. Response to Incident: First aid rendered Law enforcement notified Other, describe: Emergency room visit Refused treatment Physician notified Participant/family interviewed Reported to DHS-OIG Reported to Elder Abuse 46. If applicable, did reporter discuss with the individual activities to prevent a similar incident from occurring in the future No Yes, describe: 47. Did the incident occur when a provider was present or was scheduled to be present? Yes No Print Name of person completing report: Title: Date of report: Time of report:
Page 5 of 6 Critical Event Internal Review (To Be Completed by MFP Agency) Date of Review (MM/DD/YYYY): MFP Agency: Lead Reviewer Name: Title: Phone: ( ) Email Address: Agency Address: City Zip Names and Titles of Other Individuals Present for Critical Incident Review (if any): Name Title Documents for critical event review: Participant record Hospital/ED record if available Assessment of risk and mitigation plan : Staff recommendations based on critical event: Additional staff training needed Changes in MFP policy or procedure Recommendation summary: Other comments by agency staff member completing critical event internal review:
Page 6 of 6 Critical Event External Review (To Be Completed by UIC College of Nursing Staff) Date of External Review (MM/DD/YYYY): Reviewer 1: Reviewer 2: Summary of staff recommendations based on critical event: One Month Post-Incident Follow Up Summary and Recommendations (completed by UIC staff): Attach additional pages if needed.